197606902-2-7-2023-31-AS-NMAN-D3GMMY-20240318094438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606902
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:51:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230202133910

FACILITY NAME:	OLIVE BRANCH ASSISTED LIVING, THE		FACILITY NUMBER:	197606902
ADMINISTRATOR:	CHARLES ARRIETA		FACILITY TYPE:	740
ADDRESS:	10215 BALBOA BLVD.		TELEPHONE:	(818) 368-8581
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	146	CENSUS: 77	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Charles Arrieta		TIME COMPLETED:	04:54 PM

ALLEGATION(S):

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Staff are not properly assessing residents before admissions

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 9:15 am to investigate the above allegation. LPA met with the assistant administrator and disclosed the reason for the visit.
LPA conducted interviews with (5) staff members and three (3) out of (8) residents between 9:15am – 2:40 pm. In addition, LPA reviewed facility records at 11:34 am and requested copies of pertinent documents relevant to the investigation at 1:14 pm.
LPA conducted a physical plant tour at approximately 9:40 am to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

Staff are not properly assessing residents before admissions
It was alleged that Staff are not properly assessing residents before admissions.
(Cont. to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230202133910

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE BRANCH ASSISTED LIVING, THE	FACILITY NUMBER: 197606902
	VISIT DATE: 02/07/2023

NARRATIVE

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(Cont from 9099)

Interviews with administrators revealed all residents are properly assessed before being admitted
The administrators also revealed prospective residents must have one of the following combinations at admissions or sent prior to admissions:
Physicians’ assessment and Appraisal
Medical record and Appraisal

LPA Smith reviewed eight (8) out of (77) random resident records each containing the physician’s assessment or medical record and appraisal documents.

Based on interviews and records review there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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